Structure & Membership

EPI Program Member Application

March 20, 2016

Program Information

Program Name

Agency's Name

Website

Address

City

Postal Code

Contact Information

Contact Name(required)

Phone

Email

EPI Program Staff

Please list all individual staff, psychiatrists, and psychologists associated with the program, their position, their email and their FTE, eg. 1 FTE or .5 FTE. These names will be added to the EPION distribution list to receive notification of resources and other appropriate communications.